Trends in COVID-19 public health intervention adherence and vaccine hesitancy in South Africa: 2020–2021

South Africa’s stringent national lockdown Regulations served to contain the spread of COVID-19, but at a tremendous social and economic cost. The prioritisation of public health intervention adherence in combination with widespread vaccination coverage is critical in the effort to save lives without endangering livelihoods − but for these interventions to have an impact, sufficiently high levels of public acceptance and adherence are required. We assessed changes in attitudes and adherence between May/June 2020 and April/May 2021 using longitudinal individual-level data from five rounds of the National Income Dynamics Study − Coronavirus Rapid Mobile Survey, a nationally representative survey conducted during the COVID-19 pandemic. We used these weighted data to estimate relevant population estimates over the period under review. We observed a large increase in the prevalence of mask-wearing over time, from just half of all adults (53%) in May/June 2020 to the vast majority (83%) in April/May 2021. Hand hygiene decreased by approximately 20 percentage points over the same 12-month period (67% to 48%). Staying home and physical distancing adherence remained relatively low. On aggregate, the proportion of adults who reported ‘some’ combination prevention behaviour (either mask-wearing or hand hygiene) increased over the year. In high-risk groups, the prevalence of mask-wearing among the hypertensive and obese adult sub-populations increased substantially, from approximately 55% in May/June 2020 to over 80% one year later. Similar trends were noted for those aged 60 years and older and those with other chronic conditions. Vaccine acceptance when first estimated in February/March 2021 was relatively high at 71%, and increased further by April/May 2021 to 76%. As expected given the surge of COVID-19 cases, we observed a strong increase in mask-wearing adherence and intention to be vaccinated. Adherence to hand hygiene declined considerably over time, and staying at home and physical distancing remained low. Implications for policymakers are to continue with accurate, continuous, and targeted communication, health systems strengthening, and supporting multi-disciplinary research.